Paeds

Question 1

Paeds - Bronchiolitis vs Croup - def? Sx? Ix? Mx? RFs?

Answer 1

Mx:

• Bronchiolitis (from RSV, <1yr) - conservative (simple analgesia) + Palivizumab for prevention
• Croup - oral dexamethasone 0.15mg/kg + neb O2 & adrenaline

Question 2

Wheeze vs stridor?

Answer 2

• Wheeze – lower/small airways/bronchioles in lungs compressed –> whistling on expiration (exactly like how you whistle) – not during inspiration as stretching lung open so bronchiole diameter increases
• Stridor – narrowing of upper airways/trachea/larynx + tissues floppy –> rattling of airways during inspiration and a little during expiration (louder during inspiration as breath in harder – struggling to draw in air so working really hard)

Question 3

Acute Asthma Mx in kids

Answer 3

In acute asthma attack breathing fast/hard so CO2 should be very low –> given situation normal/high PaCO2 is ABNORMAL

Question 4

Long-term asthma Mx in kids?

Answer 4

• <5yrs:
  
  • 1^st line – SABA (reliever)
  • 2^nd line – if atopic –> 8wk trial medium-dose ICS (preventer)
  • 3^rd line
    
    • Steroid-unresponsive (recurrent Sx <4wks) –> low-dose ICS
    • Steroid-responsive (recurrent Sx >4wks) –> another 8wk course medium-dose ICS
  • 4^th line – LTRA
  • 5^th line – specialist advice
• 5-16yrs:
  
  • 1^st/2^nd line - If SABA insufficient to control symptoms or bad enough symptoms at first presentation give SABA + ICS (morning and evening everyday 1 puff)
  • 3^rd line - Leukotriene receptor antagonist (e.g., montelukast) –> block pro-inflam cytokines from arachidonic acid pathway (w/ COX)
  • 4^th line - If LTRA not working add on LABA (either continue/discontinue LTRA)
  • 5^th - If doesn’t work start maintenance & reliever therapy (MART) = 1 inhaler with ICS + LABA (morning and evening everyday) + used for relief as well instead of SABA inhaler
  • 6^th line – OCS
  • 7^th line – specialist advice

Question 5

Spectrum of wheeze in kids

Answer 5

• Can grow out of viral-induced wheeze – small airways more prone to constriction –> as grow this can become less of an issue
• Bronchiolitis is Dx if <1yr instead of viral-induced wheeze

Question 6

Types of vomiting in kids

Answer 6

Question 7

GORD Mx in kids

Answer 7

Question 8

Pyloric stenosis - def? Ix? Mx? In KIDS

Answer 8

Question 9

Cow’s milk protein allergy in kids

Answer 9

Question 10

Jaundice breakdown in children?
What is the major concern with jaundice?
Management of jaundice?

Answer 10

< 24 hrs - pathological, usually haemolysis

Haemolytic disorders
* Rhesus haemolytic disease - anaemia, hydrops (2+ compartments oedema) and hepatosplenomegaly
* ABO incompatibility - less severe than above, no hepatosplenomegaly, Hb normal, DAT/Coomb’s +ve
* G6PD def (M>F)
* Hereditary spherocytosis
Congenital Infection - growth restriction, hepatosplenomegaly, thrombocytopenic purpura

2 days-2 wks
* Physiological Jaundice - bilirubin risen as adapting to transition from foetal life
* Breast Milk Jaundice (type of physiological jaundice)
* Dehydration
* Inf
* Other (polycythaemia, Crigler-Najjar syndrome)

> 2 weeks** - persistent/prolonged neonatal jaundice**
* Unconj hyperbilirubinemia (MOST COMMON) - breast milk jaundice (most common), inf (UTI), congen hypothyroidism (coarse facial features)
* Conj hyperbilirubinaemia (>25umol/L) - pale stools + dark urine ± hepatomegaly/poor weight gain. Causes - neonatal hepatitis syndrome, biliary atresia ≥1 bile duct abn narrowed/blocked/absent

Kernicterus - encephalopathy from deposited unconj bilirubin in basal ganglia/brainstem nuclei
* Acute –> lethargy, poor feeding
* Severe: irritability , hypertonia, seizures, coma -> If survive: Choreoathetoid CP (damage to basal ganglia), learning difficulties, deaf
* Kernicterus –> brain damage in severe rhesus haemolytic disease
* RARE NOW with prophylactic anti-D immunoglobulin for rhesus-negative mothers

Management
* Physiological –> reassurance/observe
* Pathological unconj - for phototherapy (+ hydration) +/- exchange transfusion (if Kernicterus)
* Pathological conj: Tx cause, biliary atresia for surgery
* Breast milk jaundice - temporary cessation of breast feeding with supplemental feeding + treat as above

Question 11

Tx of jaundice in kids

Answer 11

• Very high levels of bilirubin –> kernicterus (in brain)
• IVIG in context of haemolytic diseases (ABO/rhesus haemolytic disease) –
  
  • Rhesus - abs from mother bind to RBCs –> move to spleen, in spleen receptors identify and bind to these abs –> RBCs destroyed.
  • Instead IVIG bind to receptors in spleen preventing spleen binding to RBCs

Question 12

Constipation in kids Mx?

Answer 12

• On exam feel for impacted stool
• Dig into social aspects of constipation – look for precipitants e.g., diet, difficulty outside on home –> consider in conservative management
• Osmotic laxative –> water moves into intestinal lumen from surrounding tissues
• Stimulants –> contraction of intestines helping to pass bolus of faecal matter

Question 13

Hirschsprung - paeds - def? Ix? Mx?

Answer 13

• No innovation from myenteric/submucosal plexus in HD
• Normally GI system has its own brain – enteric nervous system

Question 14

Intussusception - paeds - def? Sx? Ix? Mx?

Answer 14

• Rectal air insufflation – pump air from back end to make bowel pop back into shape
• If recurrent –> check for Meckel’s diverticulum - slight bulge to diverticulum present at birth –> technetium-99m pertechnetate scan ‘Meckel’s scan’

Question 15

Key features of tetralogy of fallot - paeds?

Answer 15

Question 16

Paeds congenital heart disease - breakdown?

Answer 16

Cyanotic:

• Tetralogy of fallot
• Transposition of great arteries

Acyanotic:

• ASD, VSD, AVSD, PDA

Question 17

Cyanotic congenital heart disease - presentation? Ix? Mx?

Answer 17

Question 18

Acyanotic congenital heart disease types?

Answer 18

Question 19

Complications of acyanotic congenital heart disease?

Answer 19

Question 20

Anaphylaxis in paeds - def? signs? Mx?

Answer 20

• Give nebs Salbutamol if evidence of widespread wheeze
• A-E assessment but EASY as airway is constricted (stop at A)
• Chlorphenamine = antihistamine
• Tip for PACES – give 2 EpiPen’s (one for school, one for parents)

Question 21

DKA paeds - aims of Tx?

Answer 21

Question 22

Fluids in DKA in paeds?

Answer 22

• Over 24hrs – give maintenance + ½ deficit (as this is done over 48hrs)
• 20ml/kg 0.9% for normal children, 10ml/kg 0.9% for DKA

Question 23

Status epilepticus in paeds - def? Ix? Mx?

Answer 23

Question 24

Developmental dysplasia of hip - screening? Mx?

Answer 24

Question 25

DDH vs Perthes vs SUFE

Answer 25

* **SUFE** – obesity, older (10-15yrs) --> internal fixation * **PD** – ADHD/short, younger (5-10yrs) --> conservative (analgesia, mobilisation) * **DDH** - baby (<1yr), bilateral --> Pavlik harness

Question 26

What is MAHA - paeds?

Answer 26

* Problem in small blood vessels --\> shred RBCs --\> schistocytes on blood film * Mechanism NOT disease

Question 27

Haemolytic uraemic syndrome - presentation paeds?

Answer 27

* E. coli --\> _diarrhoea_ in children, toxin damaging endothelium --\> platelet aggregation/_consumption_ --\> narrow path of RBCs/slice --\> reduction in renal perfusion --\> _renal failure_ * Occurring specifically in glomerular vessels

Question 28

Thrombotic thrombocytopenic purpura presentation paeds?

Answer 28

* Not enough ADAMTS13 --\> more vWF multimers = sticky --\> platelet coagulation --\> narrow path of RBCs/slice --\> reduction in end organ perfusion * Occurs all over the body with the most obvious area being the brain --\> confusion

Question 29

Disseminated intravascular coagulation - paeds - presentation?

Answer 29

* Exposure to lots of TF (sepsis/tumour/pancreatitis/trauma) --\> factor 7 --\> 7a --\> causes lots of platelet aggregation/consumption + coagulation factor consumption

Question 30

Preclinical breakdown of paeds haematological conditions - MAHA vs HUS vs TTP vs DIC

Answer 30

Question 31

Clinical breakdown of paeds haematological conditions - MAHA vs HUS vs TTP vs DIC

Answer 31

Question 32

Paeds nephrotic vs nephritic syndrome Clinical breakdown of renal disease - minimal change disease vs post-strep glomerulonephritis vs IgA nephropathy & HSP

Answer 32

**Nephritic syndromes** - blood/protein loss Post-streptococcal glomerulonephritis * 4-6 wks after streptococcal pharyngitis (GAS)/skin infection * Presentation: oedema, HTN, macroscopic haematuria, proteinuria * Ix: low C3 lvls, high ASOT * Mx: BP control Goodpasture syndrome * Triad: glomerulonephritis, pul haemorrhage, anti-GDM ab formation * Haemoptysis + haematuria in SBAs Alport’s syndrome * X-linked hereditary + haematuria + hearing loss * Female carriers may have haematuria HSP - IgA AI hypersensitivity vasculitis (IgA complexes deposit in small blood vessels of skin/joints/kidneys/GI tract) * NOTE: IgA nephropathy (Berger's disease) is renal-specific while HSP is widespread * Most common vasculitis of childhood <5yrs * Often preceeding throat/URTI infection (can be GI) - mildly ill, low grade fever * PC: palpable purpuric rash on buttocks (symmetrical erythematous macular), abdo pain, arthritis/arthralgia, glomerulonephritis * Dx - clinical Dx: palpable purpura + ≥ diffuse abdo pain/typical histopath (leucocytoplastic vasculitis/prolif glomerulonephritis with IgA deposits)/arthritis or arthraliga/renal involvement (proteinuria/haematuria) *Ix: urine dip, BP, FBC (can have raised Pl/raised WCC with eosinophilia), ESR (raised), Cr (raised with renal involvement), IgA (raised) * Mx: normally self-limiting -> refer to hospital ?monitoring for abdo/renal complications **Nephrotic syndrome** - urinary protein loss >3.5g/day, low albumin, oedema Minimal change disease * SBAs: swollen eyes/testes, 3+ protein on urine dip * Features: proteinuria, oedema (periorbital/scrotal), low albumin (<30), high lipids, thrombophilia * Ix: renal biopsy - electron microscopy = fusion of epithelial podocytes “minimal change as such minimal change in pathology" * Mx: CS (pred)

Question 33

Give overview of haemorrhagic disease of newborn

Answer 33

Haemorrhagic disease of newborn = Vit K def bleeding (VKDB) * Vit K low in neonates - req to prod coag factors 2/7/9/10 * Exclusively problem of breast fed babies (bottled milk contains vit K) * Bleeding sites - umbilicus, mucous membranes, GI tract, circumcision, venepunctures * IC bleeds can occur - main cause of mortality/morbidity * Mx: single dose IM Vit K given after birth, if severe bleed may need FFP

Question 34

Gastro Paeds DDx

Answer 34

Question 35

Vaccination Schedule

Answer 35

Question 36

What is the tx for pinworm?

Answer 36

Mebendazole + repeat dose after 2-3wks

Question 37

Paediatric key congenital syndromes

Answer 37

Question 38

Causes of meningitis in children

Answer 38

* Neonatal to 3 months - **GBS, E. coli, Listeria** * Older - **N. meningitidis, S. pnuemo**

Question 39

Primitive reflexes

Answer 39

Question 40

Dev milestones

Answer 40

Question 41

Wilm's tumour overview

Answer 41

Wilm's tumour - abn prolif metanephric blastema cells * Most common renal tumour in kids, 3-5yrs * PC: abdo mass +/- abdo pain, HTN, fever, haematuria, anaemia * Mx: very treatable - surgery/chemo/radio